EFFICACY OF PREOPERATIVE ASSESSMENT TOOLS IN

PERIOPERATIVE PATIENT CARE; A NURSING PERSPECTIVE

A STUDY IN NAIROBI, KENYA.

AUTHOR

OMONDI LILIAN ADHIAMBO

MScN, BScN, ORN

A PROPOSAL SUBMITTED IN PARTIAL FULFILMENT FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY OF UNIVERSITY OF

NAIROBI.

MAY, 2010

DECLARATION

This thesis proposal is my original work and has not been presented in any other

institution for examination

Sign .

Date .

CERTIFICATE OF APPROVAL

The proposal has been developed under supervision and approval of the following

Supervisors;

1. Dr. Grace Omoni.

Senior lecturer School of Nursing Sciences, University of Nairobi

2. Dr. Mary Wangari Kuria. (PhD, MMed (Psychiatric), MBChB).

Lecturer, School of Medicine, department of psychiatric, University of Nairobi,

···~'B.w.1·0.~··················

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DEDICATION

This work is dedicated and to my family for their continuous support and to the honor of

the late Professor Joyce Musandu for her inspirations.

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ACKNOWLEDGEMENT

I am very grateful to my supervisors Dr. Omoni, Professor Ogendo and Dr. Wangare for

their devotion, moral and academic support. I also thank everyone assisting me in one

way or the other towards the success of this study.

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TABLE OF CONTENT

DECLARATION ii

CERTIFICATE OF APPROVAL ii

DEDICATION iii

ACKNOWLEDGEMENT iv

TABLE OF CONTENT v

LIST OF FIGURES vii

OPERATIONAL DEFINITIONS viii

ABBREVIATIONS x

ABSTRACT xi

CHAPTER 1: INTRODUCTION 1

1.1 Background Information 11.2 Problem Statement 41.3 Justification 61.4 Hypothesis 71.5 Research question 81.6 Aim 81.7 Specific Objective 8

CHAPTER 2: LITERATURE REVIEW 9

2.1: Preoperative Assessment of the Surgical Patient 92.2 Patients Evaluation Forms 132.3 Surgical Anxiety 152.4 Theoretical Frame Work of the study 19

CHAPTER 3: STUDY METHODOLOGY AND MATERIALS 25

PHASE 1 253.1.0: FORMULATION OF PREOPERATIVE PATIENT ASSESSMENT TOOLFOR PERIOPERA TIVE CARE 25PHASE 2 303.2.0: TESTING THE DESIGNED ASSESSMENT TOOL FOR VALIDITY ANDRELIABILITy 30PHASE 3 363.3.0: TESTING THE DESIGNED TOOL IN ENHANCING ANXIETYREDUCTION AS A SURGICAL OUTCOME 36

BUDGET 45

v

GANTT CHART 46

REFERENCES 47

APPENDIX 1: GUIDING QUESTIONS FOR THE WORKSHOP 52

APPENDIX 2: PREOPERATIVE CHECK LIST 53

APPENDIX 3: GORDON'S TYPOLOGY OF 11- FUNCTIONAL HEALTH 54

PATTERNS GUIDE LINES 54

APPENDIX 4: A DAMMY OF THE PREOPERATIVE ASSESSMENT TOOL 55

APPENDIX 5: PHASE: 2 - AUTHORITY TO CONDUCT STUDY. 58

APPENDIX 6: PHASE: 3 - AUTHORITY TO CONDUCT STUDy 59

APPENDIX 7: STUDY PHASE 2: QUESTIONNAIRE TESTING RELIBILTY AND

VALIDITY OF THE DESIGNED ASSESSMENT TOOL: 60

APPENDIX 7: CONSENT EXPLANATION FORM 64

APPENDIX 8: FORM YA KIELELEZO CHA KIBALI.. 65

APPENDIX 9 66

QUESTIONNAIRE 2: STUDY PHASES 3 PATIENT ANXIETY EVALUATION 66

APPENDIX 10: APPENDIX MASW ALI YA SEHEMU YA TATU YA UTAFITI; 70

UKAGUZI KUHUSU JINSI MGONJWA HANA VYOJIHISI KUHUSU HOFU YA

UP ASUAJI. 70

APPENDIX 11: AMSTERDERN PREOPERATIVE ANXIETY INFORMATION 73

SCALE 73

APPENDIX 12: MAP OF KENYATTA NATIONAL HOSPITAL 74

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LIST OF FIGURES

Figure 2.1: Importance of preoperative assessment by the perioperative nurse .40

Figure2.2: Study Flow Chart .41

Figure 3: Map ofKNH 74

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OPERATIONAL DEFINITIONS

Anesthesia is a deliberate creation of painless and muscle relaxation state to a surgical

patient with or without loss of consciousness achieved by use of drugs to ease the

surgical process

Anesthetist is a medical doctor a nurse or a clinician trained to administer anesthesia.

Anxiety is an emotional reaction elicited by stress, fear and worry (of surgery in this

context) manifested as somatic, experiential and interpersonal phenomenon whose

observable characteristics are physiological changes such as increased respirations, heart

rate and elevated blood pressure. In this study anxiety will be measured by the patient's

perception of hislher anxiety state which he/she will translate to the corresponding

description of the anxiety levels as will be provided

Assessment in this context refers to preoperative evaluation of a surgical patient during

preoperative ward visit by the perioperative nurses in order to complete the preoperative

preparation while gathering data pertinent to the planning of actual surgical care of the

patient and documentation of such evaluation.

Checklist is a list that acts as a reference to verify specific items of preoperative

preparation of a surgical patient. It is usually filled in the surgical ward and upon arrival

to the OT, the receiving nurse review the list to confirm preparation. The list varies from

hospital to hospital although the key concepts are the same according to World Health

Organization (WHO) standards.

Collaborative health care refers to all healthcare personnel contributing their expertise

towards the care of a surgical patient

Elective surgery is scheduled or planned surgery.

Elective Cases are a category of patients scheduled for elective surgery

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Emergency Surgery refers to surgery for a category of patients for immediate surgical

remedy failure to which morbidity or mortality ensues and preoperative preparation

protocol can be breeched.

Perioperative nurses are nurses working in theatre who care for the patients during the

three phases of surgery; preoperatively from the time patients are received in theatre and

before induction of anesthesia; intraoperatively form induction of anesthesia, during the

actual surgical procedure until the patient leaves the operating table; and postoperatively

from the time the patient leaves the operating table to Post Anesthetic Care Unit (PACU)

until discharge to the ward or from the operating table and transfer to Critical Care Unit

(CCU).

Preoperative assessment tool is the assessment tool succinct to perioperative patient

care that will be designed by the perioperative nurses guided by perioperative objectives

for such assessment; the Association of peri-Operative Nurses (AORN) standards of

practice and practical experience. The tool will serve as a documentary evidence for the

assessment.

Preoperative visit is ward visit by a number of perioperative nurses the night before

elective surgery for acquaintance, orientation to the operating room, evaluation of the

patients' readiness for surgery, assessing actual surgical needs, and allaying surgical

anxiety. The assessment information should be disseminated to the rest of the nurses for

effective planning of quality perioperative care, for effective collaboration and efficient

use of theatre space.

Surgical team members are nurses in the operating room, the surgeon, assistant surgeon

and the anesthetist who primarily participate in the actual surgical procedure.

Collaborating members include the radiographer and theatre technicians among others.

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ABBREVIATIONS

APAIS

AORN

CNO

DRGs

JCAHO -

KNH

NANDA -

NATN

NNAK

OR

OT

PACU

SPSS

WHO

Amsterdam Preoperative Anxiety and Information Scale

Association of peri- Operating Room Nurses

Chief Nursing Officer

Diagnosis Related Groups

Joint Commission of Association of health Care Organizations

Kenyatta National Hospital

North American Nursing Diagnosis Association

National Association of Theatre Nursing.

National Nurses Association of Kenya

Operating room

Operating theatres

Post Anesthetic Care Unit

- Scientific Package for Social Sciences

- World Health Organization

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ABSTRACT

Preoperative patient assessment by perioperative nurses IS critical in planning,

preparation and implementing individualized patients' surgical care with an ultimate goal

of safe and quality surgical outcomes. The busy theatre schedules seldom permit an

objective ward visit to perform such assessment. Perioperative nurses perform this

assessment when the patient is already in theatre and this is seldom practiced.

Perioperative nurses often rely on preoperative assessment by ward nurses and the

anesthetists' review to verify preoperative patient preparation, using a preoperative

checklist. Checklists and theatre schedules do not adequately address the actual

procedural needs of the nurse and the patient. The result of which has led to cancellation

of surgery due to excessive anxiety of the patient, delays in surgery resulting from

inadequate preparation causing ineffective use of operating room, fragmented nursing

care due to lack of adequate and perhaps the cause of unexplained death on the operating

table. Postoperatively, some patients still have myths about surgery which should have

been clarified during the assessment. The aim of the study is to formulate, evaluate and

validate a preoperative patient assessment tool succinct to perioperative nursing to

enhance safe and quality surgical care. There is no known study that has addressed the

efficacy of focused preoperative patient assessment by the perioperative nurses in

planning and executing safe and quality perioperative care. The tool is intended to

complement preoperative checklists and theatre schedules in enhancing quality surgical

outcomes.

This will be a descriptive study that will be conducted in three phases. Phase 1; involves

the formulation of the assessment tool by the perioperative nurses. The study

population will be all perioperative nurses working in Kenya who will attend the work

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shop organized through the National Nurses Association of Kenya (NNAK) Theatre

Chapter. The sample size will be 384 nurses. The study tool will be discussion questions

for the workshop formulated by the researcher based on peri operative patient assessment

objectives, the Association of Perioperative Nurses (AORN) standards for preoperative

patient assessment and preoperative checklists obtained from various hospitals in Kenya.

Phase 2 will be testing the designed tool for validity and reliability The tool will be

administered for use by the peri operative nurses working in both private and public

hospitals in Kenya. The sample size will be 82 nurses. Purposive sampling will be

employed to select hospitals with at least S trained preoperative nurses to include

Kenyatta National Hospital, the Nairobi Hospital, Moi Teaching and Referral Hospital,

and Armed Forces Memorial Hospital for cost effectiveness from a compiled list of

trained peri operative nurses working in the OT and their respective hospitals.

Phase 3 will be evaluating enhanced anxiety reduction as surgical outcome after

using the designed assessment tool. This will be a pre-and post-test control

experimental study which anxiety levels of patients prepared for elective surgery using

the designed tool and those prepared routinely using will be assessed and compared. The

participants will be stratified by gender and randomly assigned to the experimental group

or control group. The study area will be Kenyatta National Hospital (KNH) general

surgical wards SA, SB and SD. Patients' anxiety levels will be determined moments

before and 12 hours after surgery in the surgical wards using Modified Amsterdam

Preoperative Anxiety Information Scale (APAIS) adapted from Amsterdam Preoperative

Anxiety and Information Scale AP AIS to suit the local situation. The sample size will be

96 participants.

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Data analysis will be done using SPSS. In phase I and 2 descriptive statistics will be

used. In phase 3 Paired sample T- test and Independent sample T- test will be used for

testing mean differences between the experimental and control groups. The Chronbach's

alpha will be set at 0.05 corresponding to 95% confidence limit.

The authority to conduct the study will be obtained from KNH Ethics and Research

committee and the selected hospitals for study. Informed consent will be obtained from

all the participant and confidentiality and anonymity will be observed.

The study will take duration of three years at a cost of approximately Ksh. 454,960.00

(four hundred and fifty four thousand, nine hundred and sixty Kenyan shillings).

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